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Some perspective on medical errors

October 27, 2010

I’m not sure if this post will make you feel better or worse about the metal RI Hospital surgeons left in a woman’s scalp or the forceps they left in another patient’s abdomen.  These mistakes are called “never events” by the medical community. They’re preventable and they should never happen.

But they do, more than you’d think.  And they happen all over the country.  Few states publicly report these mistakes, and those that do rarely report them as close to the actual event as Rhode Island does.

Data from Massachusetts gives a point of comparison.  The state just started publishing medical errors online in 2008.  It releases a report and a spread sheet listing the errors by hospital.

Here’s MA’s list of medical errors for 2009-

Massachusetts Acute Care Hospital SREs by Number and Percentage:

January through December, 2009 Event Count Percent
Fall 199 52%
Stage 3 or 4 Pressure Ulcer 65 17%
Retained Foreign Object 42 11%
Wrong Site Surgery 24 6%
Wrong Surgical Procedure 9 2%
Medication Error 7 2%
Sexual Assault 6 2%
Device Malfunction 6 2%
Burn 4 1%
Maternal Death / Disability 4 1%
Restraints/Bedrails 4 1%
Physical Assault 4 1%
Suicide/Suicide Attempt 3 1%
Hypoglycemia 2 1%
Air Embolism 2 1%
Elopement 2 1%
Wrong Patient Surgery 0 0%
Hyperbilirubinemia in Neonate 0 0%
Death < 24 Hours ASA 1 Patient 0 0%
Contaminated Drugs or Device 0 0%
Infant Discharged to Wrong Person 0 0%
Transfusion Error 0 0%
Spinal Manipulation 0 0%
Artificial Insemination Error 0 0%
Electric Shock 0 0%
Oxygen or Gas Error 0 0%
Abduction 0 0%
Impersonation of Health Professional 0 0%
Total 383 100

I’ve put retained foreign object in bold- that’s the number of times surgeons leave forceps, metal, whatever inside a patient after surgery.  This happened 42 times last year.  Check out wrong site surgeries- another error that gets a lot of attention in RI- 24 times last year.

Yes, Rhode Island is much smaller than MA- they have about 6.5 million people.  We have about a million.  In that case, you’d think they’d have 6.5 times as many errors as RI, but it’s more.  I have a call out to the Department of health to see our actual count of medical errors for 2009, but it terms of the reporting I’ve done, I can only remember two wrong site surgeries at RI hospital and one near miss at the Miriam.

But those are just two hospitals and MA has many more medical centers than we do.  True.  So, let’s check the data by hospital.

Here are all of the hospital that either had a wrong site surgery or a retained foreign object last year-

Hospital Name                            # Wrong site 2009            #  Retained object 2009

BAYSTATE MEDICAL CENTER                     2                                                  2

BERKSHIRE MED CTR                                       0                                                  1

BETH ISRAEL DEACONESS MED CTR          1                                                  2

BEVERLY HOSP/BEVERLY CAMPUS          3                                                 0

BRIGHAM & WOMEN’S HOSPITAL               2                                                 3

CAMBRIDGE HLTH ALLIANCE                     1                                                  0

CAPE COD HOSPITAL                                        1                                                  0

CARITAS HOLY FAMILY HOSPL                 0                                                  2

FAIRVIEW HOSPITAL                                      0                                                  1

FALMOUTH HOSPITAL                                    0                                                  1

FAULKNER HOSPITAL CORP.                        0                                                 1

HARRINGTON MEMORIAL HOSPITAL      0                                                 1

JORDAN HOSPITAL                                            1                                                 2

LOWELL GENERAL HOSPITAL                      0                                                 1

MASS EYE & EAR INFIRMARY                      1                                                 0

MASS GENERAL HOSPITAL                             3                                                6

And the list goes on….

When’s the last time Mass General apologized for a wrong site surgery?  The hospital had 3 last year as well as 6 objects left inside a patient.

Again, these events should never happen, but there’s something wrong with our hospital systems in general, not just Rhode Island’s hospitals.

4 Comments leave one →
  1. Sally Mae permalink
    October 28, 2010 10:54 pm

    Thank you for the comments left regarding other hospitals. The Nurses and Surgical Technologist at RI Hospital work deligently for their patients. These mishaps have caused the personnel much hardship and anguish to themselves. They take pride in their jobs and their main concern is their patients saftey and welfare.

    The management, administration and physicians need to be on the same page; which they are not. The administration has failed their mission to give the best care possible. Is it all about the MONEY???

    Thank you all for supporting our Staff.

    Best Wishes and Support to those of you that save lifes everyday.

  2. October 29, 2010 1:07 am

    Thanks for reading my blog Sally Mae! I’m glad you enjoyed the post.

  3. October 29, 2010 1:57 pm

    Thanks Megan for writing about this important topic. The truth is that retained surgical items are the most frequent “Never Events” in surgery and occur way too often, several times a day across the US. Most studies show that the most frequent retained item is actually surgical sponges and gauze, about 70% of the time, and because these typically create serious infection, they are usually considered the most dangerous items. In all hospitals across the country, surgical teams use repetitive manual counting techniques in an effort to avoid this issue. Recently new technology such as the use of radiofrequency identification (RFID) has been introduced. While there are also other technologies out there to augment the manual count, only RFID is able to both count the sponges and locate missing ones in the patient or elsewhere in the OR, giving a double layer of protection. The incremental cost per surgery is modest and typically offers a quick payback to the institution through the avoidance of a single incident, let alone the potentially life-threatening risk this creates for patients. Simply stated, the goal should be ZERO, and technology can help hospitals get there. If anyone is interested in learning more, go to http://www.clearcount.com or send a follow-up comment. Thanks, Jim

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  1. More on medical errors « The Pulse: health care in RI

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